Aneurysm

Introduction: The management of patients with ruptured cerebral aneurysms and severe vasospasm is subject to considerable controversy. Described herein is an endovascular technique to simultaneously address both aneurysmal rupture and vasospasm, demonstrating the efficacy of treatment. Methods: A series of 11 patients undergoing simultaneous endovascular treatment of ruptured aneurysms and vasospasm were reviewed. After placement of a guiding catheter within proximal internal carotid artery for coil embolization, an infusion line of nimodipine is wired to one hub, and of a microcatheter is advanced through another hub (to select and deliver detachable coils). Nimodipine is then infused continuously during coil embolization. Results: This technique was applied to 11 ruptured aneurysms accompanied by vasospasm (anterior communicating artery, 6 patients; internal carotid artery, 2 patients; posterior communicating and middle cerebral arteries, 1 patient each). Aneurysmal occlusion by coils and nimodipine-induced angioplasty were simultaneously achieved, resulting in excellent outcomes for all patients, and there were no procedure-related complications. Seven patients required repeated nimodipine infusion. Conclusions: Our small series of patients suggests that the simultaneous endovascular management of ruptured cerebral aneurysms and vasospasm is a viable approach in patents presenting with subarachnoid hemorrhage and severe vasospasm. O 090 A Child With Intracerebral Mycotic Aneurysms


Children Hospital number 2; Ho Chi Minh City, Vietnam 2 University of Medicine and Pharmacy of Ho Chi Minh City; Vietnam
A boy 10 year-old, neither history of infection nor congenital heart diseases, suddenly had severe headache, vomiting, and mild fever for two days. His head CT Scan revealed subarachnoid hemorrhage in the frontal interstice. And subsequent transfemoral cerebral angiography (DSA) revealed that there were two aneurysms from the distal branch of the Right anterior cerebral artery. These others cerebral arteries were normal. After diagnostic a few days, he underwent microsurgery for clipping aneurysm, but the surgery was unsuccessful because of the brain oedema. The neurosurgeon did only craniotomy for decompression. After the surgery, his GCS was 15 points. Then, he was treated by endovascular therapy after 7 days onset. During the second angiogram, the second new aneurysm was found nearby and distal to the 1st one. We suggested mycotic aneurysm and deployed two coils sacrificed two aneurysms segment. After embolization the patient had no deficit and no fever, he was treated with dual antibiotic agent. By the 20 th day, he suddenly had seizures, and unconsciousness rapidly. His GCS was 6 points and head CT Scan revealed a massive parenchymal hemorrhage in the Left occipital, where is not related to both aneurysms. Emergency surgery was performed with hematoma removal and decompressed craniotomy. After the surgery 6 months, he is conscious, can sit firmly but he can't walk himself. He is treating by physiotherapy and rehabilitation. Intracerebral mycotic aneurysm is rare and difficult to treat.
We report an unusual case of cerebral aneurysmal subarachnoid hemorrage (SAH) with Fabry's disease. A 42-year-old woman presented with aneurysmal SAH which is originated a saccular aneurysm of the right posterior communicating artery. This patient was treated by an endovascular coil embolization of aneurysm. Postoperatively, the pa-tient recovered well without neurological deficit. During an admission, patient had a sign of proteinuria in urine analysis. In kidney needle biopsy, pathologic findings showed the suggestive of nephrosialidosis (mucolipidosis of lysosomal stroage disease) which is consistent with a Fabry's disease. Fabry's disease presented with aneurysmal SAH, especially in middle-aged is uncommon, but could be a clinical concern. Further investigation to reveal risk factors, vascular anatomy, and causative mechanisms of a Fabry's disease with aneurysmal SAH.

O 093 -Spontaneous Epidural Hematoma after Stent-Assisted Coiling for Ruptured Intracranial Aneurysm
Cho Chun Sung, Ko Jung Ho 359 Manghyangro, Korea Introduction: Coiling of intracranial aneurysms has become the treatment of choice and has partly replaced neurosurgical clipping in most neurosurgical institutions. However, in difficult aneurysms with a very complex neck configuration, primary bypass of the aneurysm neck using any kind of microguidewires or microcatheters may also fail. The Neuroform stent is a device specifically designed for use in cerebral vessel and is increasingly being used in the embolization of wide-necked aneurysms, but complication and long-term patency are unsatisfactory. Recently, the use of stent-assisted coiling with preservation of the parent vessel lumen has been described in some series. Most studies have shown that with the advances in device technology intracranial stenting is feasible. lntracranial epidural hematoma (EDH) is usually a consequence of head injury. But, spontaneous epidural hematoma can occur in patients with paracranial infections, bleeding or coagulation disorder, vascular malformation, and neoplastic disorder. We present first case report demonstrates delayed spontaneous EDH occurring as a complication of stent assisted coiling of a ruptured intracranial aneurysm.
Case presentation: This 59-year-old woman was transferred from a local hospital due to symptoms of severe headache and decrease mentality. Brain CT scan revealed a subarachnoid hemorrhage with blood clot in basal cistern (Figure 1). On the first day in the hospital, three dimensional (3D) -CT angiography and diagnostic cerebral angiography performed. 3D CT and TFCA revealed a large widenecked aneurysm of the left ICA (Figure 2). After a discussion of management options, vessel preservation was attempted by means of stent-assited coil-  Discussion: Spontaneously occurring EDH is now a well-known entity. However, the spontaneous occurrence of an EDH after coil embolization has far never been reported in the literature. The etiology of spon-ing of the aneurysm. The patient was not pretreated with antiplatelets medication due to no time in emergency state. Following induction of intravenous sedation with propofol, a 6-French Envoy guiding catheter was placed in the ICA. The patient was anticoagulated with I.V. administered heparination maintaining the activated clotting time at 2.5 times the basal level. After successful stent placement, coil embolization was performed with detachable coils through a microcatheter (Excelsior SL-10; Target Therapeutics) placed in the aneurysm through the interstices of the stent (Figure 3). Heparinization was not reversed at the end of the endovascular procedure. The patient was maintained on daily aspirin and clopidogrel after stenting. Follow-up CT scan was performed at 10 days revealing a epidural hematoma within left frontal side ( Figure 4). And then we are performed to craniotomy with hematoma removal ( Figure 5).  Background and Purpose: Protective/remodeling techniques for treating wide-necked intracranial aneurysms are constantly sought. However, their utility may be limited in lesions that incorporate the mouths of acute-angled efferent branch vessels. Furthermore, passage of a protective microcatheter may be challenging if a small branch is extremely tortuous. This study was conducted to explore a novel method of treating wide-necked aneurysms, utilizing microguidewire protection.
Methods: A microcatheter is first passed into parent artery (proximal to aneurysm) to position a microguidewire proximally in the involved branch. A second microcatheter is then inserted into aneurysmal sac. Advancement of the protective microcatheter forces the microguidewire to shift, thus covering aneurysmal neck.
A framing coil may then be placed within aneurysmal sac, under microguidewire protection. After completing initial coil insertion, easing of tension on the microcatheter allows separation of protective microguidewire and frame coil, confirming stability of the initial coil.
Results: This technique was applied to 11 intracranial saccular aneurysms of M1 segment (n=6), MCA bifurcation (n=4), and AcomA (n=1) with success, combining stent protection in two patients. Coil embolization was thus facilitated, resulting in excellent outcomes for all patients. No morbidity or mortality was directly related to microguidewire protection.
Conclusion: Our small study suggests that microguidewire protection may be a safe alternative, if traditional remodeling or protective options are infeasible due to intrinsic vascular properties. This technique is particularly suited for treatment of wide-necked aneurysms where passage of protective microcatheters into involved branches is not achievable.

O 095 -Mechanism of the Enlargement of the Cerebral Aneurysm. CFD Analysis of Basilar Aneurysm with Long-term Follow-up
Takashi Yamanouchi 1 , Shigeru Miyachi 1 , Takashi Izumi 1 , Noriaki Matsubara 1 , Takumi Asai 1 , Keisuke Ota 1 , Kazunori Shintai 1 , Masaru Fujii 2 , Akihiro Andou 2 , Toshihiko Wakabayashi 1 taneously occuring EDH can involve three mechanisms. The first is neighboring infection, which is usually located in the paranasal sinuses and the middle ear. Two theories have been proposed to explain this mechanism. The first theory is that infection-related arteritis may weaken meningeal vessel walls, resulting in bleeding into the extradural space. The second theory is that accumulation of exudate, pus, or air in the extradural space causes progressive detachment of the dura mater from the inner table, and this process leads to diffuse extradural venous bleeding. An elegant hypothesis advanced by Gordon specifies that dura mater detachment and subsequent bleeding may be enhanced by intracranial hypotension resulting from an occult cerebrospinal fluid fistula, a common finding in patients who present with spontaneously occurring EDH caused by otorhinolaryngological infection. Second possible mechanism for the spontaneous occurrence of hemorrhage in the extradural space is an iatrogenic, acquired, or congenital coagulation disorder. Our patient had not undergone anticoagulant or antiaggregate therapy, and complete blood coagulation analysis revealed no hematological abnormality. The third potential underlying mechanism of spontaneously occurring EDH is vascular malformation, including dural AVM, hemangioma of the dura mater or diploe , and middle meningeal artery aneurysm Conclusion: The occurrence of an EDH after coil embolization is rare. Given the patient's clinical history and the absence of both coagulation abnormalities and pericranial infection, the most likely explanation would be bleeding from an occult dural or extradural vascular malformation. However, more clinical data with longer follow-ups are needed to help establish the this event after coil embolization stressful to the parent artery in the deployment, conformable to the tortuous parent artery, and available for semi-jailing technique. Stent-assisted coil embolization using Enterprise VRD can be a feasible and effective treatment in selected patients with ruptured vertebrobasilar dissecting aneurysmsnot suitable for parent artery occlusion.

Kyung-Sool Jang
Beverly Aagaard-Kienitz, MD; Aquilla S. Turk, DO The saccular aneurysms of vertebrobasilar junction are rare, but when present they are often associated with a fenestration of basilar artery. Basilar artery fenestration is reported in 0.6% of angiograms and in about 5% of some autopsy series. The complex anatomy of this region, such as multiple small perforators to the brain stem and multiple lower cranial nerves, makes surgical clipping difficult. Recently, it has been suggested that endovascular coiling is a treatment alternative to surgically difficult aneurysms. We present 2 cases of vertebrobasilar junction aneurysms associated with fenestration of basilar artery in four patients, which were treated with endovascular coiling with stents.
Objective: Aneurysms located at the distal portion of the posterior inferior cerebellar artery (PI-CA) are rare, and their clinical features are not fully understood. We report 4 cases and analyze their clinical characteristics and outcomes from three different treatment strategies.
Material and Methods: We retrospectively reviewed 4 cases with a distal posterior inferior cere-1 Nagoya University Hospital Neurosurgery 2 Toyota communication system Co. Ltd. Purpose: Cerebral aneurysms may enlarge due to various factors and situations, such as hypertension, size, shape, projection and location. It is well known that larger aneurysm have a higher tendency to rupture. Therefore the prediction of the enlargement of an aneurysm is important to define the future outcome. We focused on the inflow energy into the aneurysmal sac based on computational fluid dynamics (CFD) method to identify the relationship with the enlargement from the long-term follow-up aneurysms.
Methods: CFD study was performed for 5 basilar aneurysms follow-up for a long time (3.6y-9.4y: average 7.3y). 3D reconstruction images were obtained from 3DCT angiography. CFD analysis was performed by the non-stationary finite volume method (Toyota Communication System Co., Ltd.). We investigated wall shear stress (WSS), inflow energy (IE) and pressure energy (PE) of the aneurysmal neck and studied the relationship between these parameters and the volume enlargement rate (VR) and the surface enlargement rate (SR).
Results: IE and PE were found to have a strong correlation with VR (correlation coefficient: IE 0.905, PE 0.922) and SR (correlation coefficient: IE 0.950, PE 0.979). Other factors including WSS did not a show definite relationship.
Conclusions: In our study, the higher IE or PE may have caused the enlargement of the aneurysm. In fact, WSS, the famous factors have influencing the rupture, had less relationship with enlargement. Even in the limited study situations of specific aneurysms, IE and PE may become a predictor of aneurysmal enlargement.

Naoko Miyamoto
Isao Naito 3-26-8, Ootomo-cho, Maebashi; Gunma, Japan Five patients with ruptured vertebra basilar dissecting aneurysms, to which parent artery occlusion can not be applied, were treated by using Enterprise VRD. Thelocation of the dissecting aneurysms was vertebral artery in three patients and basilar artery in two. In all patients, Enterprise VRD was successfully deployed in the dissecting segment, and the coils were inserted in the aneurysmal dilatation by semi-jailing technique. Ischemic complication occurred in two patients and rebleeding occurred in one patient 4 months after the treatment. Favorable outcome was obtained in four of the five patients.
Conclusion: Almost of A1A had arisen at both ends, and their characteristics were differ each other. Proximal A1A had short distance from ICABF and directed to posterior, appropriate micro-catheter shaping and neck-remodeling technique will be needed especially in endovascular treatment. And distal A1 aneurysms are carefully select treatment strategy because of vulnerable to rupture. Background: A wide neck aneurysm in the vertebrobasilar junction is difficult to treat especially in a patient presented with SAH and there is no opposite vertebral artery.
Case report: A 61-year-old man presented with severe headache one day before and came to hospital with GCS 13 points and subarachnoid hemorrhage on his head CT scan. A wide neck aneurysm was found on the CTA at the right vertebrobasilar artery. On the angiogram showed the wide neck aneurysm 5x6mm at the right vertebrobasilar and there is no contralateral vertebral artery on the left side. Endovascular treatment was performed after 10 days of SAH with the "jailing" technique: 1 Leo Stent (BALT) and 3 coils were used. The aneurysm was bellar artery (PICA) aneurysm among 368 cases of intracranial aneurysms rupture that were surgically treated during the period from November 2008 to October 2013. The following data were analyzed: age, sex, aneurysm size, Hunt-Hess grade at presentation, angiographic characteristics, and clinical treatment outcome determined by Glascow outcome scores (GOS). Treatments performed included 2 endovascular sacrificing the parent arteries of the aneurysms, 1 selective coiling, and 1 clipping after failure of endovascular treatment.
Results: Four patients (4 all females; mean age: 58 years; mean aneurysm size: 4.7 mm) presented at our facility with subarachnoid hemorrhage (SAH) caused by aneurysm rupture. Two patients presented with Hunt-Hess grades 5; two others were in Hunt-Hess grades 2 or 3. The location of the aneurysm was telovelotonsillar in 3 cases and cortical in 1 cases. The angiographic findings were 1 fusiform dissecting aneurysm and 3 saccular aneurysms. One patient with fusiform dissecting aneurysm died because of no procedural related Rt. MCA infarction after endovascular sacrificing the parent arteries. The surviving three patients had GOS of 5.
Conclusion: Treatment decisions were based on the individual clinician's experience, without a standardized approach to treatment. Endovascular sacrificing the parent artery of the distal PICA aneurysm result in permanent occlusion of the lesion. But selective coiling with parent artery preservation can be considered whenever the anatomy allowed the coils to be retained in the aneurysm sac. The type of parent artery and particularly the collateralization of its distal part should be considered as an essential factor to take into consideration when choosing a treatment strategy. etiology (n=3), choroidal segment of anterior choroidal artery (n=2), posterior inferior cerebellar artery (n=2), superior cerebellar artery (n=1), posterior cerebral artery (n=2) and middle cerebral artery (n=1), anterior cerebral artery (n=1). One case is a salvage therapy using glue for intraoperative aneurysmal rupture during coil embolization. Mean clinical and imaging follow-up duration was 18 months. (range, 8-32months).
Results: : In all 9 patients, embolization using glue resulted in complete obliteration confirmed by angiography and no recurrence during follow-up period. Complication related to the procedure occurred in 2 cases; one is occipital lobe infarction due to parent artery occlusion in P3 aneurysm, another is rebleeding in cerebellar arteriovenous malformation with flow related aneurysm.
Discussion: Rapid injection of n-butyl cyanoacrylate for distal aneurysms with or without low-flow arteriovenous malformations is not required. A careful continuous injection and appropriate catheter positioning may result in successful embolization. We suggested that the adhesion of catheter was rare even if remarkable reflux to proximal vessels in the treatment using low concentration of n-butyl cyanoacrylate.
Conclusion: Endovascular internal trapping of distal cerebral aneurysm using n-butyl cyanoacrylate was feasible, safe, and effective. Unusually an aneurysm is the cause of hemorrhage in patients with moyamoya disease (MMD). We present a case of a ruptured thalamoperforator artery aneurysm treated with n-butyl cyanoacrylic acid (nBCA) embolization in a patient with MMD.
A 51-year-old female presented with suddenly decreased mentality and left side 3rd cranial nerve palsy. Initial brain computed tomography and angiography showed subarachnoid hemorrhage, both distal internal carotid arterial occlusion and strong enhancing nodule at left side posterior communicating artery. Digital subtraction angiography reveals occlusion at the terminal portion of the both internal carotid artery with development of moyamoya vessels and aneurysm like vascular pouch at left side P1 portion. A 50% solution of nBCA and ethiodol cured with keeping the normal flow from the right vertebrobasilar artery. The patient had a good recovery and discharged 4 days after procedure without any deficits.
Conclusion: The 'jailing' technique can be used to treat wide neck aneurysms. This technique will be more difficult and dangerous when the artery is small and much more attention when the parent artery with no collateral circulation.

O 101 -«Super-Masamune» Balloon Microcatheter
Masayuki Ezura, Naoto Kimura Hiroshi Miyagino,Sendai,Japan We have already developed Masamune balloon microcatheter. We recently developed "Super-Msamune", a new type of Msamune, in which the balloon is modified into more compliant. The balloon itself is very compliant. It is more compliant than HyperForm, but is not single lumen but double lumen. It easily herniates to free space and makes better neck protection possible. Because of double lumen, it can be used only for neck plasty balloon, but also for the catheter for coil insertion. We will show initial experiences of this balloon in this presentation. The balloon is still immature now and further modification would be necessary. It would become commercially available within 1 year.

O 102 -Endovascular Treatment of Distal Cerebral Aneurysm Using N-Butyl Cyanoacrylate for Various Etiologies
Masanori Suzuki, Shushi Kominami, Shiro Kobayashi, Akio Morita Kamagari 1715, Inzai City; Chiba, Japan Objective: Distal cerebral aneurysms associate with various mechanisms for their formation and their surgical treatment are often difficult because of their difficulty of operative orientation. We report nine patients with distal cerebral aneurysm treated by embolization using n-butyl cyanoacrylate with or without coil.
Methods: Between 2007 and 2013, nine patients with ruptured distally located cerebral aneurysm were treated with n-butyl cyanoacrylate. We performed the embolization of aneurysmal sac and proximal parent vessels; endovascular internal trapping different from only proximal parent artery occlusion. The etiology and location of aneurysm were as follows: mycotic aneurysm (n=1), arteriovenous malformations (n=4), dissection (n=1), unverified Purpose: The purpose of this study was to evaluate clinical results in the patients with severe subarachnoid hemorrhage (Hunt and Hess Grade V) treated with aggressive ICP control and brain protection using Hypothermia therapy (HT) subsequent to aneurysmal coil embolization (CE.) Material and Methods: From 2003 Jan to 2013 Dec, we have treated 36 patients (F:M=24:12) with Hunt Grade V (GCS3:7, 4:19, 5:3, 6: 5) were treated with HT subsequent to CE. From the initial CT scan, Fisher's CT group were G3 in 34 and G4 in 21. The location of aneurysm were ACA in 16, MCA in 3, ICA in 5, B-V in 8.
Results: From 2003 to 2009, we treated 22 patients with 35°C mild hypothermia for 72hours. 8 (36%) patients had good outcomes (Glasgow Outcome Scale: GOS 1 and 2). 7 patients took the GOS5 (spasm 4, brain injury 2, pulmonary embolism 1). From 2010 to 2013, we treated 12 patients with 36°C hypothermia for 72 hours. 5(41%) patients had good outcomes. 3 patients took the GOS 5(spasm 1, brain injury 2). Pneumonia was found as complications frequently, but the death due to pneumonia was not found. In our institution, outcome of severe subarachnoid hemorrhage gradually become good. Endovascular CE and HT contributes to the improvement of Results:Conclusion: Severe subarachnoid hemorrhage has many cases having difficulty in treatment and outcome is very poor. But we can expect some better outcome by CE and HT.
was injected into the aneurysm. Postembolization angiography demonstrated no evidence of residual aneurysm. There were no procedural complications and at 1 year follow-up she remained neurologically normal. One year follow-up magnetic resonance angiography showed no residual aneurysm.
In MMD associated with intracranial aneurysms, coil embolization was performed for saccular aneurysms whereas endovascular parent artery occlusion with glu was conducted for pseudoaneurysms. The endovascular occlusion of aneurysms on the collateral vessel in MMD with nBCA might be an effective treatment option.

O 104 -Endovascular Treatment of an Isolated Lateral Spinal Artery Aneurysm Causing Subarachnoid Hemorrhage
Jae Il Lee, Jun Kyeung Ko

Department of Neurosurgery, Pusan National University Hospital, Busan, Republic of Korea
This case report describes an aneurysm arising from the lateral spinal artery. Spinal artery aneurysms that are not associated with other vascular abnormalities or other entities are exceptionally rare. Especially isolated lateral spinal artery (LSA) aneurysm is extremely rare with only one case of isolated LSA aneurysm rupture reported to date. We report a case of LSA aneurysm presenting with subarachnoid hemorrhage (SAH).
A 67-year-old man presented with sudden onset of headache and neck pain. A computed tomography (CT) scan showed perimesencephalic and perimedullary SAH and subdural hematoma extending caudally to upper cervical spinal cord. A conventional angiogram demonstrated a right LSA aneurysm. Onyx embolization of the aneurysm was performed. During procedure, the patient developed sudden cardiac arrest. After resuscitation, the patient developed "lock-in-syndrome". Retrospective angiography review revealed Onyx migration to distal posterior inferior cerebellar artery and contralateral LSA. We describe the first treatment example of an isolated LSA aneurysm using Onyx with a catastrophic complication. This extremely rare case illustrates how knowledge of the angiography and super-selective microangiography aids the correct diagnosis, choice of treatment modality and the prevention of endovascular or surgical treatment complications.

O 105 -Clinical Outcome of Severe SAH Patients Treated with Hypothermia Subsequent to Emergency Aneurysmal Coil Embolization
Methods: All patients who underwent one-stage coiling for two or more aneurysms were identified from a prospectively registered neurointerventional database over 10 years. The patient characteristics and clinical and angiographic outcomes at discharge and follow-up were retrospectively evaluated.
Conclusions: One-stage coiling of multiple aneurysms seemed to be safe and effective, with low morbidity and mortality.

Department of Neurosurgery, Tokyo Medical University Hospital
Introduction: Stent-assisted coiling on intracranial aneurysm has been considered as an effective technique. But dual antiplatelet therapy when a stent is placed for assistance in the treatment of ruptured aneurysms is of concern. A case of ruptured basilar tip large aneurysm was treated with endovascular techniques and is described here.
Case: A 71-year-old woman with a history of hypertension had a sudden onset double vision and a severe headache, which the brain CT showed diffuse subarachnoid hemorrhage (SAH), Fishergroup 3 and Hunt & Kosnic grade II.The diagnostic cerebral angiography revealed a basilar tip aneurysm Background: Isolated dissecting aneurysms of the posterior inferior cerebellar artery (PICA) are rare, but have a high risk of re-bleeding. Recently, endovascular treatment has been proposed as an alternative to surgery, but still they present a therapeutic challenge. We report results of various endovascular treatments in patients with isolated PI-CA dissecting aneurysms.
Methods: Eleven patients (mean age: 44.4 years, range: 15-58, M:F=5:6) with isolated PICA dissecting aneurysms were treated by endovascular techniques (graft stent insertion in three, coiling of aneurysmal sac in four, stent assisted coiling of aneurysmal sac in two, and occlusion of parent artery by coil in two) in our institution between March 2005 and May 2012 and followed for up to 45 months. Clinical presentations were acute subarachnoid hemorrhage in seven patients, ischemia in two, severe headache in one and an incidental aneurysm of PI-CA in a ruptured anterior choroidal artery aneurysm. Preprocedural occlusion test performed in five patients. We carefully examined the presence of contrast filling of the PICA by collaterals during parent artery occlusion Results: On immediate follow-up angiograms, dissecting aneurysms were successfully occluded in all patients. PICA flow was well preserved in nine of eleven patients by collaterals and sluggish PICA flow in remaining two with parent artery occlusion. One patient developed ipsilateral PICA territory infarction two days after parent artery occlusion, but fully recovered at discharge. There were two procedure-related thrombo-embolic complications, but no neurologic sequela occurred. Angiographic follow-up (mean: 18 month, range: 3-45 months) was available in all patients. Follow-up angiograms showed total aneurysmal occlusion with well preserved PICA flow by collaterals in all patients. There was no newly developed neurologic event or re-bleeding in all patients during clinical follow-up periods (mean: 40.3month, range: 6 -60 months).
Conclusions: Various endovascular techniques are feasible and relatively effective, safe treatment modality of the isolated PICA dissecting aneurysm. Background and Purpose: The aim of this study was to evaluate the safety and effectiveness of onestage coiling for multiple intracranial aneurysms.

O 107 -Treatment of Multiple Intracranial Aneurysms with One-Stage Coiling
with acetazolamide(ACZ) injection revealed no reduction of cerebral blood flow and normal reactivity to ACZ.
Results: We performed coil embolization for ruptured basilar tip aneurysm under the general anesthesia. Two GDC-10 360 coils and two 10 hydrosoft helical coils were successfully deployed and tightly packed. Balloon and stent-assisted coiling was not used. The post-intervention course is uneventful.
Conclusion: It seems that a proximal stenosis of ICAs of patients with moyamoya disease can progress into complete occlusion and this may be another characteristic morphologic feature of moyamoya disease. Neurointerventional coil embolization for basilar tip aneurysm associated with moyamoya disease is safe and useful even without assistance of balloon or stent. Regular follow up angiograms is essential and additional embolization may be needed even though there was no perfusion defect seen on the perfusion CT.

O 110 -Recanalization of Spontaneously Occluded Vertebral Artery Dissection after Subarachnoid Hemorrhage: 2 Case Reports
Norio Ichimasu, Daisuke Watanabe, Hirofumi Okada 7-1, Nishi-Shinjuku 6 choume, Shinjuku-ku, Tokyo, Japan Case 1: A 42-year-old woman with grade IV SAH according to the World Federation of Neurological Surgeons (WFNS). Initial cerebral angiography showed spontaneously occluded vertebral artery dissection. Serial angiography 7 days after the onset of subarachnoid hemorrhage revealed that the affected artery was recanalized, and we performed parent artery occlusion of right vertebral artery.
Case 2: A 49-year-old woman presented with a ruptured vertebral artery dissecting aneurysm manifesting as subarachnoid hemorrhage (WFNS grade IV) followed by acute occlusion and early recanalization (1 day after the onset) of the affected artery. Therefore, we performed parent artery occlusion for the affected artery.
Discussion: Spontaneous occlusion is a rare manifestation of ruptured vertebral artery dissection. In cases where hemorrhage occurs, occlusion of the lesion is effective in reducing the risk of re-bleeding. However, deciding on treatment is difficult in uncommon cases in which occlusion occurs immediately after hemorrhage. We will provide 2 case reports, that we experienced ruptured vertebral artery dissecting aneurysm followed by spontaneous acute occlusion and early recanalization. The progressive angiographic changes of the ruptured vertebral artery dissection and the endovascular treatment of such arterial dissections will be discussed. that measured 19 mm×15 mm of aneurysm body with a 14mm neck, sharing bilateral posterior cerebral artery (PCA) origin.We decided to deploy Yconfigured stents using enterprise VRD 28mm with double microcatheter technique. For a preparation of stenting, dual antiplatelet therapy was performed. Body filling of the aneurysm was showed immediately after coiling, which was possible maintaining patency of bilateral PCA. A week later, follow up angiography showed neck remnant without body filling. The patient was no neurological deficit and got a good recovery.
Conclusion: It is difficult and challenging to treat of ruptured basilar tip large aneurysm with wide neck, and is necessary to use stents to keep patency of PCAs. Dual antiplatelet therapy for stenting is necessary to prevent ischemic events, but there is a risk of a hemorrhage and re-rupture of aneurysm. We considered how to use stenting and antiplatelet therapy for ruptured basilar tip large aneurysm.
Background and Purpose: Direct surgical clipping for aneurysm with underlying moyamoya disease is difficult and the morbidity is high due to the extensive collaterals, as well as the already compromised cerebral blood flow. We report here on a case of a ruptured basilar tip aneurysm that was successfully treated with coil embolization in the bilateral cervical internal carotid arteries ( ICA) occlusion with abnormal vascular networks which mimicked moyamoya disease.
Material and Methods: A 43-year-old man with familial history of moyamoya disease presented with subarachnoid hemorrhage. Digital subtraction angiography demonstrated complete occlusion of bilateral ICAs at the proximal portion and a ruptured aneurysm at the basilar artery bifurcation. Aneurysm size was 4.3mm width x 6.1mm height x 3.0mm neck with ruptured bleb on dome. Each meningeal artery supplied the anterior cranial base, but most of both hemispheres were supplied with blood from the basilar artery and the posterior cerebral arteries through a large number of collateral vessels to the ICA bifurcation and the anterior cerebral and middle cerebral arteries. Perfusion CT Jung Ho Ko, Chun Sung Cho, Young-Joon Kim Department of Neurosurgery, Dankook University College of Medicine,359 Manhyangro;Cheonan,Choongnam,Republic of Korea. Object: In cases of fetal type artery incorporated on aneurysm or broad necked appearance, it could be very difficult to treat posterior communicating artery (PcomA) aneurysms endovascularly. With intracranial stenting increasing in recent years, and the improvement of stent-assisted coiling, several techniques have been developed for broad neck PcomA aneurysms in which the aneurysms are incorporating the origins of the branches. The authors introduce the retrograde navigation of stent and further coiling in second stage for ruptured PcomA aneurysm.
Materials and Methods: Fifty two year old female with SAH (H&H grade 3) was shown broad neck right PcomA anerysm with fetal type PcomA incorporated to the aneurysm neck. The distal internal carotid artery (ICA) and PcomA angle was acutely curved. In the beginning waffle cone stent technique was applied and the coiling was successfully deployed without any complication. However 18 months after follow up angiography revealed recanalization. Retrograde stenting consisted of series of technical steps: 1) stent catheter navigation from contralateral left ICA, left A1. 2) Through Acom artery, the stent was navigated to right A1, right ICA in a retrograde fashion. 3) The stent catheter introduced into the aneurysm sac recanalized and selected to the PcomA reversely. 4) The stent was deployed from the right PcomA to right ICA. 5) A microcatheter for coiling was introduced through right ICA and further coiling was performed.
Results: The aneurysm was almost completely coiled by the second stage stent assisted coiling. One year after follow up, the aneurysm was secured.
Conclusion: The authors successfully treated one patient with ruptured broad neck ICA-PcomA aneurysms using retrograde stenting through the narrow Acom artery approach. It may constitute a viable alternative treatment option for PcomA aneurysms with difficult configurations and acute ICA-Pcom artery angle.

O 113 -Endovascular Coil Embolization in Internal Carotid Artery Bifurcation Aneurysms
Objective: Aneurysms arising from pericallosal artery (PA) are uncommon and challenging to treat. The aim of this study was to report our experience with endovascular treatment of ruptured PA aneurysms.
Methods: From September 2003 through May 2012, 30 ruptured PA aneurysms in 30 patients were treated at our institution via endovascular approach. Procedural data, clinical and angiographic results were reviewed retrospectively.
Results: The immediate angiographic control showed complete occlusion in 21 (70.0%) patients and near-complete occlusion in 9 (30.0%). Procedure-related complication occurred, including procedure-related rebleeding in six and thromboembolic event in two. Preoperative contrast retention was most strongly associated with a increased risk of procedure-related rebleeding. At the end of the observational period, 18 patients were independent with a mRS score of 0-2, while the other 12 were dependent or dead (mRS score, 3-6). Adjacent hematoma was associated with a increased risk of poor clinical outcome. No neurologic deterioration or bleeding was seen during the follow-up period (mean, 32.7 months) in all survived patients. Seventeen of 23 surviving patients underwent follow-up conventional angiography (mean, 16.5 months). The result showed stable occlusion in 14 (82.4%), minor recanalization in two (11.8%), and major recanalization in one (5.9%), who had required recoiling.
Conclusion: Our preliminary experience demonstrates that endovascular treatment for ruptured PA aneurysms is feasible and effective. Procedure-related rebleedings occur far more often (20.0%) than has been generally suspected in other locations and were associated with a preoperative contrast retention. An existing adjacent hematoma was a predictor of poor clinical outcome.

O 112 -Endovascular Coiling with Retrograde Stent Navigation Through Anterior Communicating Artery for Recurred Broad Necked Posterior
Communicating Artery Aneurysm. Technical Note dural vertebral dissecting aneurysms were treated with endovascular modalities, which consisted of internal coil trapping, stent-assisted coil embolization and multiple stents overlapping placement. Post-procedural complications including infarction and recurrent hemorrhage were retrospectively reviewed and clinical outcomes were evaluated at discharge and follow-up clinics 6 months later using mRS.
Results: Seventeen patients with ruptured vertebral dissecting aneurysm were enrolled in the present study. Internal coil trapping was performed 13 patients and stent-assisted coil embolization was applied to 2 patients. Multiple stents placement and combined surgical bypass with coil trapping were used for managing the other 2 patients. Post-procedural infarction was developed in 12 of 17 patients and recurrent hemorrhage was reported on 3 patients who underwent stent-assisted coil embolization and internal trapping. Nine patients with sole infarction showed excellent or favorable clinical outcome of mRS from 0 to 3. Three patients with rebleeding and concomitant infarction were revealed poor outcomes of mRS 4 or 6. Imaging follow up was obtained in 14 survived patients, which revealed complete obliteration of the dissecting aneurysm.
Conclusions: Even high frequency of post-procedural infarction, clinical outcome of endovascular treatment for ruptured vertebral dissecting aneurysms was favorable. Poor clinical outcome was associated with recurrent hemorrhage. Therefore prevention of recurrent SAH outweighs the risk of ischemia in the PICA territory and lateral medulla.

O 115 -Thromboembolic Complications in Patient with Clopidogrel Resistance after Coil Embolization for Unruptured Intracranial Aneurysm
Background and Purpose: The purpose of the present study was to report our experience with endovascular treatment of 17 patients with ruptured intradural vertebral dissecting aneurysm.
Method and materials: Between November 2007 and November 2013, 20 patients with ruptured intra-ter technique for small intracranial aneurysm with wide necks.
Materials and Methods: Between January 2012 and November 2013, 19 small unruptured intracranial aneurysms with wide necks (defined as maximum diameter <4mm and dome to neck ratio 1.5) in 19 patients (mean age, 53.2 years, range, 26-70; 8 men and 11 women) were treated with the doublemicrocatheter technique. Clinical and radiologic outcomes were retrospectively evaluated.
Results: All the aneurysms (middle cerebral artery: 1, anterior communicating artery: 5, anterior choroidal artery: 1, ophthalmic artery: 2, posterior communicating artery: 5, basilar artery: 2, posterior inferior cerebellar artery: 1, and superior cerebellar artery: 2), except for one patient, were successfully treated with the double-microcatheter technique only. A stent was needed in just one case, where the aneurysm was located at the top of the basilar artery. Only one case had a complication during the procedure: A thrombus occurred around the embolized aneurysm, but was dissolved completely without symptoms. Immediate post-embolization angiographies demonstrated complete occlusion in 10 patients, and a minimal residual neck in 9 patients. The mean packing density was 35% (range, 19-67). During the clinical follow-up period (mean, 4.4 months; range: 0-11), all patients reported an mRS score of 0. Follow-up MR angiography was available for 13 aneurysms at 0-9 months. All aneurysms showed complete occlusion except for 1 minimal residual neck that required no further treatment.
Conclusion: The double-microcatheter technique appears to be feasible and effective in the treatment of small unruptured intracranial aneurysms with wide necks.

Deparment of Neurosurgery, Jeju Halla General Hospital; Korea
A 56-year-old man presented with sudden bursting headache and slight mentality change. The brain CT angiography showed prepontine SAH and a small saccular aneurysm from the perforating artery of the right side mid basilar artery. Cerebral angiography revealed a ruptured brain stem perforating artery (BPA) aneurysm associated with an arteriovenous malformation (AVM). A brain stem perforating artery (BPA) aneurysm was located on Rt. mid-portion perforating artery of basilar artery. It's 3-mm sized very small aneurysm. An arteriovenous malformation (AVM) was located Background and Purpose: Antiplatelet resistance is known to be associated with symptomatic ischemic complication after endovascular coil embolization. The purpose of our study was to evaluate the relationship between antiplatelet resistance and clinically silent thromboembolic complications using DWI in patients who underwent coil embolization for unruptured intracranial aneurysm.
Methods: Between October 2011 and May 2013, 58 patients with 62 unruptured aneurysms who were measured for antiplatelet response using Veri-fyNow assay and underwent elective coil embolization for unruptured aneurysm with posttreatment DWI were enrolled. Diffusion positive lesions were classified into three groups according to the number of lesions (n = 0 (grade O), n < 6 (grade I) and n 6 (grade II)). The relationship between antiplatelet resistance and diffusion positive lesions was analyzed.
Results: Sixty-two endovascular coiling procedures were performed on 58 patients. Clopidogrel resistance was revealed in 22 patients (37.9%) and diffusion positive lesions were demonstrated in 28 patients (48.3%); these consisted of 19 (32.8%) grade I and 9 (15.5%) grade II lesions. Clopidogrel resistance was not relevant to the development of a diffusion positive lesion (grade I and II, p = .589) but associated with the development of grade II lesions (p = .001). In the logistic regression prediction model, clopidogrel resistance was significantly associated with the development of grade II lesions (p = .001).
Conclusions: Multiple diffusion positive lesions ( 6 in number) occurred more frequently in patients with clopidogrel resistance after endovascular coiling for unruptured aneurysm. Objective: Coil embolization has become a major modality of treatment for intracranial aneurysms. However, small intracranial aneurysms are now thought to represent a higher risk of procedure-related rupture compared to larger aneurysms. This situation poses technical challenges and treatment dilemmas. Our aim in this study was to evaluate the safety and effectiveness of the double-microcathe-duced through right ICA and further coiling was performed.

O 116 -Feasibility and Effectiveness of a Double-Microcatheter Technique for a Small Unruptured Intracranial Aneurysm with a Wide Neck
Results: The aneurysm was almost completely coiled by the second stage stent assisted coiling. One year after follow up, the aneurysm was secured.
Conclusion: The authors successfully treated one patient with ruptured broad neck ICA-PcomA aneurysms using retrograde stenting through the narrow Acom artery approach. It may constitute a viable alternative treatment option for PcomA aneurysms with difficult configurations and acute ICA-Pcom artery angle. Introduction: Subclavian artery dissecting aneurysms are uncommon. The most common causes of dissecting aneurysm are trauma and infection.

O 119 -A Case of Acute Large Right Subclavian Artery Dissecting Aneurysm
Case: A 52 year-old man, known case of cirrhosis child C with E.coli peritonitis was admitted for antibiotic treatment. During admission, the doctor examined the right supraclavicular lymph nodes, then needle aspiration was done with fresh blood from injected into right subclavian artery. So, patient was refered to Ramathibodi hospital for evaluation this injury. The CTA showed a right subclavian artery dissecting aneurysm with partially thrombosed peripheral and inferior portion, covering the left sided of origin of right vertebral artery(VA), measuring about 4.6 x 5.5 x 6.2 cm. in AP, transverse and vertical diamention, respectively. This patient was sent to treat with vascular stent graft covering the origin of dissecting aneurysm. About 1 week later, the CTA showed stable dissecting aneurysm. We planned to embolized this dissecting aneurysm. The conventional angiogram showed minimally reduction of the size of aneurysm with partially contrast filling to the aneurysm from right subclavian artery and retrograde from right VA. We inserted the microcatheter from left VA through vertebrobasilar junction into the origin of right VA and dissecting aneurysm. Transarterial embolization of this dissecting aneurysm and the origin of right VA was successfully done using detachable coils. The control angiogram showed nearly complete obliteration.
Conclusion: The subclavian artery dissecting aneurysm is rare but potentially serious. The chance of ruptured dissecting aneurysm is high, that related to the sized of dissecting aneurysm.
in Rt. Cerebellopontine area, less than 3 cm sized ( Spetzler-Martin Grade 3). Initial procedure was done to aneurysm due to SAH. Successful incomplete obliteration of aneurysm rupture was done by intravascular coiling. And follow up embolization by Onyx was done to Rt. mid-portion perforating artery of basilar artery. But The AVM was not obliterated. After then 100days of 2 nd embolization of AVM by onyx, We treated radiosurgery (1500 cGy/1 time). We don't evauation of AVM situation of post SRS, because of patient had other personal cause. On recent, We studied for follow up TFCA. It's showed nearly removed of AVM nidus on Rt. Brain stem area. This case is very rare. We have been treated several various treat ment modalities.

O 118 -Endovascular Coiling with Retrograde Stent Navigation Through Anterior Communicating Artery for Recurred Broad Necked Posterior Communicating Artery Aneurysm
Young-Joon Kim, Jung Ho Ko Department of Neurosurgery, Dankook University College of Medicine,Cheonan;Choongnam,Korea . Object: In cases of fetal type artery incorporated on aneurysm or broad necked appearance, it could be very difficult to treat posterior communicating artery (PcomA) aneurysms endovascularly. With increasing of the intracranial stenting in recent years, and the improvement of stent-assisted coiling, several techniques have been developed for broad neck PcomA aneurysms in which the aneurysms are incorporating the origins of the branches. The authors introduce the retrograde navigation of stent and further coiling in second stage for ruptured PcomA aneurysm.
Materials and Methods: Fifty two year old female with SAH (H&H grade 3) was shown broad neck right PcomA anerysm with fetal type PcomA incorporated to the aneurysm neck. The distal internal carotid artery (ICA) and PcomA angle was acutely curved. In the beginning waffle cone stent technique was applied and the coiling was successfully deployed without any complication.
However 18 months after follow up angiography revealed recanalization. Retrograde stenting consisted of series of technical steps: 1) stent catheter navigation from contralateral left ICA, left A1. 2) Through Acom artery, the stent was navigated to right A1, right ICA in a retrograde fashion. 3) The stent catheter introduced into the aneurysm sac recanalized and selected to the PcomA reversely. 4) The stent was deployed from the right PcomA to right ICA. 5) A microcatheter for coiling was intro-